Adem Form 499 - Notice Of Termination - Npdes General Permit Number Alg890000
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1A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
N
T
– NPDES G
P
N
ALG890000
OTICE OF
ERMINATION
ENERAL
ERMIT
UMBER
Instructions:
NPDES General Permit Number ALG890000, which is the general permit
This form should be used to request termination of coverage under
authorizing discharges from small noncoal/nonmetallic mining and dry processing and areas associated with these activities. Please complete all
questions. Respond with “N/A” as appropriate. Incomplete or incorrect answers, or missing signatures will delay processing. If space is
insufficient, continue on an attached sheet(s) as necessary. Attach other information as needed. Please type or print legibly in blue or black ink.
Mail completed form to:
ADEM-Water Division
Stormwater Management Branch
PO Box 301463
Montgomery, Alabama 36130-1463
Item I.
Permittee Name
Facility/Site Name
NPDES Permit Number
Facility Street Address or Location Description
ALG89
County(s)
Facility City, State, Zip
Item II.
1.
Yes
No
Has all regulated activity authorized by this Permit at this facility been completed? (i.e. mining effects
removed; solid waste/debris properly disposed; all disturbed areas have been fully reclaimed, permanently stabilized, or perennial
vegetative cover established; and stormwater discharges do not represent an adverse impact to water quality.)
2.
Yes
No
N/A
If applicable, has the Permittee been released from the ADOL bond? If yes, attach a copy of the
ADOL bond release paperwork.
If “Yes” to question 1 above, skip questions 3 and 4 below:
3.
Yes
No
Has the Permittee lost operational control of the facility/site?
4.
Yes
No
Has the Permittee lost legal responsibility for the facility/site?
If “Yes” to either question 3 or 4, in order for this termination request to be granted, the Name, Phone Number, and Address of the
succeeding responsible permittee/operator(s) must be listed and the succeeding responsible operator must obtain coverage:
“I understand that discharging pollutants in storm water associated with regulated activity to waters of the State that is not authorized
by NPDES permit coverage is a violation of State law. I also understand that the submittal of this request for termination does not
release the operator from liability for any violations of this permit, ADEM Administrative Code Chapter 335-6-6, or other ADEM rules
until a complete and correct request for termination of the permit is received by the Department. I understand that the permittee,
operator, owner, contractors, separately or collectively, must retain permit coverage for mining activities until all disturbance activity is
substantially complete. I understand that should an inspection or complaint reveal significant noncompliance with ADEM rules, an
environmental problem related to the discharge of stormwater from the site or that incorrect information has inadvertently been
provided, implementation of remedial measures may be required, to include resubmittal of the NOI in order to correct any deficiencies,
comply with state and federal permitting requirements, and provide for the protection of water quality. “I certify under penalty of law
that this form, the BMP Plan, and all attachments were prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the
qualified credentialed professional (QCP) and other person or persons who manage the system or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, correct, and complete. I
am aware that there are significant penalties for submitting false information including the possibility of fine or imprisonment for
knowing violations.
Name & Designation of QCP
Signature
Date
Name & Title of Responsible Official
Signature
Date
ADEM Form 499 10/17 m3
Page 1 of 1
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